Information Collection

Focus Groups

IC 208112 under ICR 201308-0938-006 · OMB 0938-1219.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1219 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10477 Focus Groups	Form and Instruction
CMS-10477 Screener for focus group eligibility Attachment_4a_Focus Group_Screener_English_clean.docx	Form and Instruction
CMS-10477 Discussion guide for focus groups Attachment_4b_Round_1_and_2_Discussion_Guide.pdf	Form and Instruction
CMS-10477 Participant contact release form for focus groups Attachment_4d_Participant_Contact_Release_Forms_English_clean.docx	Form and Instruction
CMS-10477 Focus group consent form Attachment_4e_Consent_Form_English_clean.docx	Form and Instruction
CMS-10477 Screener_Spanish_new_clean Attachment_8a_Screener_Spanish_new_clean.docx	Form and Instruction
CMS-10477 Participant_Contact_Release_Forms_Spanish_new_clean Attachment_8d_Participant_Contact_Release_Forms_Spanish_new_clean.docx	Form and Instruction
CMS-10477 Consent_Forms_Spanish_new_clean Attachment_8e_Consent_Forms_Spanish_new_clean.docx	Form and Instruction
Attachment_4f_Reminder_Email_English_clean.docx Focus group appointment reminder	IC Document
Attachment_4c_Recruitment_Flyer_Template_English_clean.docx Focus group recruitment flyer	IC Document
Attachment_8b_Discussion Guide_Spanish_new_clean.docx Attachment_8b_Discussion Guide_Spanish_new_clean	IC Document
Attachment_8c_Recruitment_Flyer_Spanish_new_clean.docx Attachment_8c_Recruitment_Flyer_Spanish_new_clean	IC Document
Attachment_8f_Reminder_Email_Spanish_new_clean.docx Attachment_8f_Reminder_Email_Spanish_new_clean	IC Document

IC Title:

Focus Groups

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10477	Screener for focus group eligibility	Attachment_4a_Focus Group_Screener_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Participant contact release form for focus groups	Attachment_4d_Participant_Contact_Release_Forms_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Focus group consent form	Attachment_4e_Consent_Form_English_clean.docx	No	No	Fillable Fileable
Form and Instruction	CMS-10477	Screener_Spanish_new_clean	Attachment_8a_Screener_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Participant_Contact_Release_Forms_Spanish_new_clean	Attachment_8d_Participant_Contact_Release_Forms_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Consent_Forms_Spanish_new_clean	Attachment_8e_Consent_Forms_Spanish_new_clean.docx	No		Fillable Fileable
Form and Instruction	CMS-10477	Discussion guide for focus groups	Attachment_4b_Round_1_and_2_Discussion_Guide.pdf	No	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 880

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	880	880
Annual IC Time Burden (Hours)	613	613
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Focus group appointment reminder	Attachment_4f_Reminder_Email_English_clean.docx	01/15/2014
Focus group recruitment flyer	Attachment_4c_Recruitment_Flyer_Template_English_clean.docx	01/15/2014
Attachment_8b_Discussion Guide_Spanish_new_clean	Attachment_8b_Discussion Guide_Spanish_new_clean.docx	01/15/2014
Attachment_8c_Recruitment_Flyer_Spanish_new_clean	Attachment_8c_Recruitment_Flyer_Spanish_new_clean.docx	01/15/2014
Attachment_8f_Reminder_Email_Spanish_new_clean	Attachment_8f_Reminder_Email_Spanish_new_clean.docx	01/15/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.